Provider Demographics
NPI:1417929035
Name:HICKERSON, CHRISTOPHER J (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:HICKERSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 LOOKOUT CIR
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-9246
Mailing Address - Country:US
Mailing Address - Phone:316-640-8761
Mailing Address - Fax:
Practice Address - Street 1:1861 E MADISON AVE STE 400
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:KS
Practice Address - Zip Code:67037-2166
Practice Address - Country:US
Practice Address - Phone:316-789-6200
Practice Address - Fax:316-361-2635
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS603541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice